Endovascular versus Open Repair for Non-Complex Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis

The risk of rupture and mortality associated with abdominal aortic aneurysms (AAAs) necessitates timely surgical intervention. Open surgical repair (OSR) and endovascular aneurysm repair (EVAR) are the 2 primary surgical techniques, frequently compared for efficacy and safety. EVAR is less invasive and reduces perioperative mortality but carries a higher risk of long-term complications. This meta-analysis evaluates short- and long-term outcomes of EVAR and OSR in infrarenal noncomplex AAA.

A systematic review and meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Primary outcomes included perioperative mortality, long-term all-cause mortality, and aneurysm-related mortality. Secondary outcomes assessed reintervention, complication and limb graft occlusion (LGO) rates. Random-effects model were used for statistical analysis.

Compared with OSR, EVAR significantly reduced perioperative mortality (odds ratio [OR] = 0.45; 95% confidence interval [CI]: 0.27-0.75; P = 0.002; I² = 63%). At the longest follow-up (6-15 years), all-cause mortality did not differ significantly (OR = 1.06; 95% CI: 0.97-1.17; P = 0.22). Aneurysm-related mortality showed a nonsignificant trend toward higher rates after EVAR (OR = 1.17; 95% CI: 0.88-1.56; P = 0.29). Secondary interventions were significantly more frequent after EVAR (OR = 2.27; 95% CI: 1.32-3.93; P = 0.003). Pooled analysis demonstrated over 4-fold increased odds of LGO with EVAR compared to OSR (OR = 4.07; 95% CI: 2.15-7.71; P < 0.0001). Endoleaks were the most common EVAR-related complication, with higher rates of type I endoleak and LGO for Zenith Flex versus Endurant II in the Enzen Trial.

EVAR confers a perioperative survival benefit over OSR but does not improve long-term all-cause mortality. Late aneurysm-related deaths, reinterventions, and LGO are more frequent after EVAR, emphasizing the need for lifelong surveillance and careful patient selection.